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Code: E78.00

Code Name: ICD-10 Code for Pure hypercholesterolemia, unspecified

Block: Metabolic disorders (E70-E88)

Excludes 1:androgen insensitivity syndrome (E34.5-)
congenital adrenal hyperplasia (E25.0)
Ehlers-Danlos syndrome (Q79.6)
hemolytic anemias attributable to enzyme disorders (D55.-)
Marfan's syndrome (Q87.4)
5-alpha-reductase deficiency (E29.1)

Details: Pure hypercholesterolemia, unspecified

Fredrickson's hyperlipoproteinemia, type IIa
Hyperbetalipoproteinemia
Low-density-lipoprotein-type [LDL] hyperlipoproteinemia

E78

Excludes1: sphingolipidosis (E75.0-E75.3)

Guidelines: Endocrine, nutritional and metabolic diseases (E00-E89)

Excludes 1:transitory endocrine and metabolic disorders specific to newborn (P70-P74)

Note: All neoplasms, whether functionally active or not, are classified in Chapter 2. Appropriate codes in this chapter (i.e. E05.8, E07.0, E16-E31, E34.-) may be used as additional codes to indicate either functional activity by neoplasms and ectopic endocrine tissue or hyperfunction and hypofunction of endocrine glands associated with neoplasms and other conditions classified elsewhere.

For more details on E78.00 , ICD-10 Code for Pure hypercholesterolemia, unspecified , visit: https://coder.aapc.com/icd-10-codes/

perkins05

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What E/M level is this?
Thanks


established patient

Chief Complaint
cool clamy skin, abdominal pain, fever at home, hematuria

History of Present Illness
Onset this a.m. associated with frequency and dark urine

Review of Systems
Gastrointestinal: Nausea, Abdominal pain, Anorexia.
Genitourinary: No unilateral flank pain.

Health Status
Allergies: .
Allergic Reactions (Selected)
Severity not Documented
Iodine (No reactions were documented)
Medications: (Selected).
Prescriptions
Ordered
Diovan HCT 320 mg-25 mg oral tablet: See Instructions, Instructions: TAKE 1 TABLET BY MOUTH EVERY DAY, # 30 EA, 4 Refill(s), Pharmacy: Walgreens Drug Store 06637
Klor-Con 10 oral tablet, extended release: See Instructions, Instructions: TAKE 1 TABLET BY MOUTH EVERY DAY, # 30 EA, 4 Refill(s), Pharmacy: Walgreens Drug Store 06637
Lipitor 10 mg oral tablet: See Instructions, Instructions: TAKE 1 TABLET BY MOUTH EVERY DAY FOR CHOLESTEROL, # 30 tab(s), 2 Refill(s), Pharmacy: Walgreens Drug Store 06637
METFORMIN 1000MG TABLETS: See Instructions, Instructions: TAKE 1 TABLET BY MOUTH TWICE DAILY FOR DIABETES, # 60 tab(s), 1 Refill(s), Pharmacy: Walgreens Drug Store 06637
betamethasone-clotrimazole 0.05%-1% topical cream: See Instructions, Instructions: APPLY TO THE AFFECTED AREA OF GENITALIA TWICE DAILY AS NEEDED FOR SKIN IRRITATION, # 45 gm, Pharmacy: Walgreens Drug Store 06637
glipiZIDE 10 mg oral tablet, extended release: See Instructions, Instructions: TAKE 1 TABLET BY MOUTH TWICE DAILY, # 60 tab(s), 1 Refill(s), Pharmacy: Walgreens Drug Store 06637
Problem list: .
All Problems
Abnormal Chest Sounds / ICD-9-CM 786.7
Acute Bronchitis / ICD-9-CM 466.0
Acute Nasopharyngitis [common Cold] / ICD-9-CM 460
Acute Suppurative Otitis Media without Spontaneous Rupture of Ear Drum / ICD-9-CM 382.00
Acute Upper Respiratory Infections of Unspecified Site / ICD-9-CM 465.9
Allergic Rhinitis, Cause Unspecified / ICD-9-CM 477.9
Benign Essential Hypertension / ICD-9-CM 401.1
Benign Neoplasm of Skin, Site Unspecified / ICD-9-CM 216.9
Candidiasis of Skin and Nails / ICD-9-CM 112.3
Cellulitis and Abscess of Leg, Except Foot / ICD-9-CM 682.6
Colon Polyps 211.3
Contact Dermatitis and Other Eczema, Unspecified Cause / ICD-9-CM 692.9
Contusion of Foot / ICD-9-CM 924.20
COUGH / ICD-9-CM 786.2
Dermatophytosis of Groin and Perianal Area / ICD-9-CM 110.3
Diabetes Mellitus without Mention of Complication, Type II or Unspecified Type, Not Stated as Uncontrolled / ICD-9-CM 250.00
Diabetes Mellitus without Mention of Complication, Type II or Unspecified Type, Uncontrolled / ICD-9-CM 250.02
DM Type II no comp. 250.
EDEMA / ICD-9-CM 782.3
EPISTAXIS / ICD-9-CM 784.7
Family History of Diabetes Mellitus / ICD-9-CM V18.0
Family History of Stroke (Cerebrovascular) / ICD-9-CM V17.1
HEMATURIA / ICD-9-CM 599.7
Hyperlipidemia, pure 272
Hypertension 401.9
Impacted Cerumen / ICD-9-CM 380.4
Labyrinthitis, Unspecified / ICD-9-CM 386.30
LUMBAGO / ICD-9-CM 724.2
Mixed Hyperlipidemia / ICD-9-CM 272.2
Mononeuritis of Upper Limb, Unspecified / ICD-9-CM 354.9
Need for Prophylactic Vaccination and Inoculation Against Influenza / ICD-9-CM V04.81
Need for Prophylactic Vaccination and Inoculation Against Other Specified Disease / ICD-9-CM V05.8
Need for Prophylactic Vaccination and Inoculation Against Other Viral Diseases / ICD-9-CM V04.8
Need for Prophylactic Vaccination and Inoculation Against Tetanus-Diptheria [TD] [DT] / ICD-9-CM V06.5
Neoplasm of Uncertain Behavior of Skin / ICD-9-CM 238.2
Obesity / ICD-9-CM 278.00 / Probable
Obesity / ICD-9-CM 278.00 / Probable
Open Wound of Multiple Sites, Uncomplicated / ICD-9-CM 873.29
Osteoarthrosis, Unspecified Whether Generalized or Localized, Involving Lower Leg / ICD-9-CM 715.96
Other Acute Otitis Externa / ICD-9-CM 380.22
Other and Unspecified Hyperlipidemia / ICD-9-CM 272.4
Other Atopic Dermatitis and Related Conditions / ICD-9-CM 691.8
Other Bursitis Disorders / ICD-9-CM 727.3
Other Nonspecific Abnormal Findings / ICD-9-CM 796.9
Other Specific Muscle Disorders / ICD-9-CM 728.3
Other Specified Hypertrophic and Atrophic Conditions of Skin / ICD-9-CM 701.8
Pain in Joint Involving Hand / ICD-9-CM 719.44
Pain in Joint Involving Shoulder Region / ICD-9-CM 719.41
Personal History of Colonic Polyps / ICD-9-CM V12.72
Psoriasis and Similar Disorders / ICD-9-CM 696
ROSACEA / ICD-9-CM 695.3
Rosacea 695.3
Screening for Malignant Neoplasms of Colon / ICD-9-CM V76.51
Screening for Malignant Neoplasms of Prostate / ICD-9-CM V76.44
Screening for Malignant Neoplasms of Testis / ICD-9-CM V76.45
Sebaceous Cyst / ICD-9-CM 706.2
Seborrheic Keratosis / ICD-9-CM 702.1
Unspecified Disease of Sebaceous Glands / ICD-9-CM 706.9
Unspecified Disorder of Skin and Subcutaneous Tissue / ICD-9-CM 709.9
Unspecified Essential Hypertension / ICD-9-CM 401.9
Unspecified Otitis Media / ICD-9-CM 382.9
Unspecified Vitamin D Deficiency / ICD-9-CM 268.9
Urinary Tract Infection, Site Not Specified / ICD-9-CM 599.0
Venous (Peripheral) Insufficiency, Unspecified / ICD-9-CM 459.81
Vitamin D deficiency

Histories
Past Medical History: .
No active or resolved past medical history items have been selected or recorded.
Family History: .
No family history items have been selected or recorded.
Procedure history: .
Hx adenomatous colon polyps in 2004 at 57 Years.
Colon polypectomy in 1900.
Fx of L clavicle in 1900.
Toenail removal in 1900.
Social History: .
Alcohol Assessment
Never
Tobacco Assessment
Never
Substance Abuse Assessment
Never


Physical Examination
VS/Measurements
Vital Signs
Temperature Oral 98.0 DegF
Peripheral Pulse Rate 90 bpm
Respiratory Rate 24 br/min HI
Systolic Blood Pressure 126 mmHg
Diastolic Blood Pressure 68 mmHg
Mean Arterial Pressure 87 mmHg
Oxygen Saturation 91 % LOW
Pain Present Yes (Provider Not Notified)
, Measurements from flowsheet : Measurements
Height 72.00 in
Weight 397.00 lb
BSA 3.02 m2
Body Mass Index 53.84 kg/m2

General: Alert and oriented, Mild distress, Morbidly obese.
HENT: Mild scleral icterus.
Respiratory: Lungs are clear to auscultation.
Cardiovascular: Normal rate, Regular rhythm.
Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No rebound scars or hernia.
Neurologic: Alert, Oriented, Normal sensory, Normal motor function.
Psychiatric: Cooperative, Appropriate mood & affect, Normal judgment.

Review / Management
Results review: Lab results.
Glucose Urine Dipstick Negative
Bilirubin Urine Dipstick Large
Ketones Urine Dipstick 1+
Specific Gravity Urine Dipstick 1.020
Blood Urine Dipstick Large
pH Urine Dipstick 5.5
Protein Urine Dipstick 300 mg/dl
Urobilinogen Urine Dipstick 1 mg/dl
Nitrite Urine Dipstick Positive
Leukocyte Esterase Urine Dipstick Large

Impression and Plan
Diagnosis
Hematuria (ICD9 599.70).
Jaundice (ICD9 782.4).
Plan: Referred to the emergency room at for further evaluation differential diagnosis of gallstones pancreatic lesion hepatitis drug effect causing jaundice, Hematuria could be caused by renal stone hemorrhagic cystitis pyelonephritis, Both could be caused by a renal tumor.
Summary: Because of the possibility of sepsis due to biliary or renal obstruction patient referred to the emergency room.
 

missy874

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Albany
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99214

Detailed history, Expanded Problem Focused Exam, Moderate MDM.

MDM: New problem w workup, Moderate Risk--both meet moderate criteria
 

KRivers26

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I say a 99214 also. I agree...EPF History, Detailed History, and Moderate MDM....I didnt count sending the patient to the ER as additional work-up though.
 

KRivers26

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Also, the providers note of "sepsis" would count in MDM as a High risk. I counted 3 for new problem no additional work-up and 1 for labs in Data Review.
 
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